Suicide and self-harm in in-patient psychiatric units: a study of nursing issues in 31 cases

A significant number of incidents of suicide and self-harm occur whilst patients are in receipt of care as in-patients. This audit comprises 31 cases which were referred to the first author for expert opinion, each case being the subject of legal action brought by patients and/or their families. The cases were referred from 31 different NHS trusts across England. All concerned suicide/serious self-harm in people in receipt of in-patient care. The aims of this audit were to carry out a detailed assessment of the 31 individual cases, so as to provide a nursing dimension to already established enquiries in this area and also to examine whether specific issues might be the subject of more systematic research. Further, this paper aims to provide some insights in the area of litigation, where nurses are becoming increasingly involved. The same broad approach to information-gathering and analysis was used, comprising a systematic review of case records, trust policies, expert reports and, where appropriate, inquest transcriptions. The sample comprised 12 suicides and 19 cases of serious self-harm. Factors associated with these events include: being male, having a dual diagnosis of mental illness and drug/alcohol abuse, and age between 21 and 30 years. Of the 12 deaths, five occurred in hospital, four by hanging and one by drowning. The audit highlighted environmental factors associated with these events which, arguably, could be simply addressed. There was a considerable variation in the content and quality of observation policy and practice. The results of this audit point to the need for further research but, above all, provide evidence requiring urgent action by the Department of Health regarding the setting of national standards.